{"entity":{"id":"idea-pdac-enzyme-replacement-prescribing-by-default","kind":"idea","name":"Pancreatic enzyme replacement by default: prescribe at diagnosis, audit the rate, and run the trial that settles survival","aka":[],"tldr":"The pancreas makes the enzymes that digest food, and a cancer in it, or the operation to remove it, leaves most patients unable to absorb what they eat. Capsules replacing those enzymes are cheap and recommended, yet UK records show only one patient in five was prescribed them. The proposal is to prescribe by default at diagnosis, publish each hospital's rate, and run the trial never done.","summary":"Traverso and Longmire recorded in 1980 that every one of their 18 pylorus-preserving patients had marked pancreatic insufficiency and needed intensive enzyme replacement. Roberts 2019, in 4,554 UK primary care patients with pancreatic adenocarcinoma, found enzyme replacement prescribed to 21.7 percent, and in 807 propensity-matched pairs an adjusted survival time ratio of 2.62 (95 percent confidence interval 2.27 to 3.02), consistent across surgery and chemotherapy subgroups. NICE NG85 (2018) recommends enteric-coated pancreatin for unresectable disease and after resection, and the National Pancreatic Cancer Audit now reports prescribing as a performance indicator in England (the Wales data item was unavailable in the first report). The proposal has three parts: an opt-out prescription at diagnosis in every pancreatic multidisciplinary team, with dose titration by a dietitian; publication of the audit indicator by trust; and a pragmatic randomised or stepped-wedge trial of default prescribing against usual care with survival, weight and chemotherapy delivery as outcomes, since the survival association is observational and confounded by fitness. The UK figures and the audit's recommendations are on the UK and NHS page.","asOf":"2026-09-24","links":[{"label":"Roberts et al.: enzyme replacement and survival in pancreatic cancer (Pancreatology 2019)","url":"https://europepmc.org/article/MED/30385188"},{"label":"NICE NG85: pancreatic cancer in adults (2018)","url":"https://www.nice.org.uk/guidance/ng85"},{"label":"National Pancreatic Cancer Audit reports (NATCAN)","url":"https://www.natcan.org.uk/reports/?audit=pancreatic"}],"tags":["pancreatic-evidence"],"related":["idea-pdac-cachexia-trials-embedded-in-chemotherapy-trials","idea-pdac-uk-active-treatment-rate-audit-and-target"],"cancers":["pancreatic"],"sections":["supportive-care","nutrition-lifestyle"],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["whipple"],"trials":[],"people":[],"bottlenecks":["b-cachexia-supportive","b-knowledge-diffusion","b-care-fragmentation"],"keyPapers":["paper-roberts-pert-survival-pancreatic-cancer-pancreatology-2019","paper-traverso-longmire-pylorus-preservation-pancreaticoduodenectomy-sgo-1978"],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Default enzyme replacement at diagnosis raises the prescribing rate above 80 percent, and in a pragmatic randomised comparison against usual care improves weight maintenance and chemotherapy delivery, with a survival gain that is smaller than the observational estimate but real.","rationale":"The intervention is cheap, guideline-endorsed and safe; the gap is behavioural and organisational; the observational survival signal is large enough to warrant a trial and too confounded to act on alone.","test":"Stepped-wedge or cluster randomised trial of opt-out prescribing across pancreatic multidisciplinary teams, with the audit indicator as the process measure and weight, relative dose intensity and overall survival as outcomes.","maturity":"early-clinical","actor":"clinic","cost":"small","horizonYears":3},"route":"/ideas/idea-pdac-enzyme-replacement-prescribing-by-default/","neighbours":{"idea":[{"id":"idea-pdac-cachexia-trials-embedded-in-chemotherapy-trials","kind":"idea","name":"Embed cachexia treatment in chemotherapy trials: weight, muscle and treatment delivery as co-primary endpoints","route":"/ideas/idea-pdac-cachexia-trials-embedded-in-chemotherapy-trials/"},{"id":"idea-pdac-uk-active-treatment-rate-audit-and-target","kind":"idea","name":"Raise the share of UK patients who receive any active treatment, and publish it by trust","route":"/ideas/idea-pdac-uk-active-treatment-rate-audit-and-target/"}],"cancer":[{"id":"pancreatic","kind":"cancer","name":"Pancreatic ductal adenocarcinoma","route":"/cancers/pancreatic/"}],"section":[{"id":"nutrition-lifestyle","kind":"section","name":"Diet, Exercise & Lifestyle","route":"/fronts/nutrition-lifestyle/"},{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"term":[{"id":"whipple","kind":"term","name":"Whipple procedure (pancreaticoduodenectomy)","route":"/terms/whipple/"}],"bottleneck":[{"id":"b-cachexia-supportive","kind":"bottleneck","name":"Cachexia, toxicity and the limits of the patient","route":"/bottlenecks/b-cachexia-supportive/"},{"id":"b-care-fragmentation","kind":"bottleneck","name":"Fragmented care and guideline gaps","route":"/bottlenecks/b-care-fragmentation/"},{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"}],"paper":[{"id":"paper-roberts-pert-survival-pancreatic-cancer-pancreatology-2019","kind":"paper","name":"Enzyme replacement improves survival among patients with pancreatic cancer: Results of a population based study","route":"/key-papers/paper-roberts-pert-survival-pancreatic-cancer-pancreatology-2019/"},{"id":"paper-traverso-longmire-pylorus-preservation-pancreaticoduodenectomy-sgo-1978","kind":"paper","name":"Preservation of the pylorus in pancreaticoduodenectomy","route":"/key-papers/paper-traverso-longmire-pylorus-preservation-pancreaticoduodenectomy-sgo-1978/"}],"roadmap":[{"id":"pancreatic-roadmap","kind":"roadmap","name":"Pancreatic cancer roadmap: from Whipple's operation to gemcitabine, FOLFIRINOX, adjuvant chemotherapy, PARP inhibition, KRAS inhibition, vaccines and the surveillance question","route":"/roadmaps/pancreatic-roadmap/"}]}}